The Idea... Part 4

Tooth of Time - Cimarron, NM
9,003 Feet Elevation

It has been a few days of extreme busy work and sheer exhaustion, not to mention an ill child and a mound of make up homework that would rival the Tooth of Time in height (not actually, but it seems that way)... So I apologize for not adding this part of "The Idea" in a timely manner. But we must press on so that I can explain my rationale for this online journal creation and venting of my mental diatribe. And for those of you that know me... it is a good thing for me to vent from time to time (how many times can you use the word "time" in one paragraph?).

Well... It seems I promised some EMS in this part as I recall. What a better way to deliver that than by pursing where we left off regarding the intense week of travel. As I alluded to, there was finally a day in the office where I managed to get a few pressing things done. Of course, not near as many things completed as to match the rate at which projects labeled themselves as "incoming!" in the same manner and warning of an artillery shell.

That particular Friday found me waking up at 3am to be on the road by 4am. Had a short meeting to attend in Brownsburg an hour before my first EMS Commission meeting as the Chairman. Looking back... I have been on the Commission since 2005. I was voted the Vice-Chairman in 2006 by my peers on the Commission.

This sudden elevation to the Chair came as an appointment rather than an election. I am not always sure as to how government works, but I would like to think that someone (or more than one) thinks that I can handle this and do well at leading the Commission. One of the changes that I have been wanting to see for awhile has been one of perspective. Indiana's EMS Commission is by nature a reactive entity. Part of that is by design as it is a decision based body which weighs facts and impacts of a variety of issues. These range from the certifications of providers and caregivers to actually approving new rules and regulations regarding how EMTs, Paramedics and ambulances perform.

When I took the EMT course (back in 1983), there was a section of the course, near the beginning where EMTs would learn the number of people on the Commission and what the Commission was responsible for doing in regards to Indiana. Even when I became a paramedic in 1987, the Commission was still prominent and was understood to be the lead role in the continuing formation of Indiana EMS and at the same time, the watchdog over proper prehospital practice. They don't include this in curricula anymore. Now it is hard to find an Indiana EMT or paramedic who even know the Commission itself exists at all. Many times, the first time anyone has even heard of the Commission is after they have been reported for some alleged wrong-doing. Certified (and now some licensed) individuals usually have contact with an EMS Commission staff employee (or Indiana Department of Homeland Security - EMS Division) when they have a question, recertify (relicense) or need clarification on regulation. The IDHS EMS staff does the massive daily work and handles the majority of what makes EMS function on the government side of medical response. With that said, it is no wonder that there is a bit of a disconnect between the line EMS caregiver and the Commission from the bottom up perspective.

I assure you, that is not the case from the top down view. For the last several years, the Commission has dealt with some pretty big issues in the state that affect Hoosiers dramatically. The act of adopting a Trauma rule is one of those issues. It took a great deal of time, a great number of meetings, much gnashing of teeth and sack cloth renting to publish a trauma rule in the state. Many issues and opinions were in play. Many providers reported on the issue of impact regarding transporting patients out of their communities and what that would do for coverage. Whether or not paramedics (and EMTs) could handle patients for the sometimes long transport times to a designated trauma center was brought up. Many arguments even took place. But today, through hard work and consensus, a trauma rule exists. Indiana's propensity for using time as a measurement of distance even showed up and was debated as we discussed the trauma rule.

The Commission has debated adopting the new national certification levels and the attached scope of practice for each. This one is still heated even after the adoption of each level. Herein lies another reason for this blog... communication of my reasoning on certain issues.

Meetings are limited in time and scope. I would love to be able to hear every question and deliver an answer to each person attending a Commission meeting. That would be fair. We would also never finish the business at hand. Always remember this... any person can write a letter addressed to the Commission and send it to IDHS. All of the Commissioners will see it and then will be aware of your desires. Also understand that it isn't always about desires. Let me state some facts:

1) I do not hate or dislike EMT-Basic Advanced level personnel.
2) I do not hate or dislike EMT Intermediate personnel.
3) I do not hate or dislike those desiring to be the new AEMT level.
4) I am not out to get you... I really don't have the time for that...

With that said, let me explore some reasons for my actions on these topics over the last few years.

1) I have instructed no less than five EMT-Basic Advanced classes. I have worked with many great EMT-BA certified individuals. I believe that the ones I have known were all about patient care. I will tell you that I always had some qualms about the curricula. I never liked the fact that it did not teach all ECG rhythms. That just is not safe... allowing someone to use an ECG monitor but then tell them you are only going to instruct them in how to interpret 90% of the rhythms? Does that sound safe to anyone? If you are working on a truck with a medic, its all good... but what about the unit that has the EMT-BA as its highest level of provider. I worry about that person being stuck in a position of possibly not knowing a rhythm because it was outside of scope.

2) The EMT Intermediate was designed primarily for the rural setting where some paramedic skills and medications were just not frequently utilized. It was a shorter, less costly way of doing advanced life support. Here are some issues. During the time frame of the I-99 curricula (as it is referred to nationally) it was found that field intubation has a high incidence of mortality (I will not go into the reasons yet... that is a blog entry of its own). Drug errors by I-99 personnel were more frequent (this was noticed nationally (not referring to Indiana specifically). It is just the truth that there was too much skill/knowledge needed for too short of a class.

3) The new AEMT (Advanced EMT) was designed to rectify the training level and scope of the "middle ground" certification. It gives some advanced skills but limits the scope to essentials that can occur with a short time frame of training while steering clear of skills that require frequency of use to assure proficiency. This is about as close as we get to an evidence-based middle ground certification.

4) I have heard many say that they have to do the middle ground due to cost. I can tell you that the main difference in cost between and Intermediate EMT ambulance and a Paramedic ambulance was not in the equipment, drugs, vehicle or insurance... it is in payroll. So essentially what you get with the Intermediate is a lower paid, 85% paramedic. I do not think this is fair to the Intermediate. I know of some communities that send their paramedic units out on long distance transfers, leaving the Intermediate units to run the 911 calls.

5) If you... as a provider, or as a certified individual want to do all of the skills, we have a license (almost said certification) for that. It is called Paramedic. There is very little evidence-based proof regarding the impact of prehospital EMS. We now know quality CPR is the trick behind save rates. We know that Lidocaine is proarrythmic. The efficacy of c-spine immobilization is in question by neurologists. We know that IM Versed is faster than IV Versed in seizure patients (the RAMPART trial proved that... and we thought IV was always faster!). The list goes on. The middle ground desires IV therapy while we continue to learn that the effect of IV therapy on outcomes is limited. More nasal medication administration is coming. IV starts are sometimes sacrificed to get a patient to therapy 2-3 minutes faster. All of this information is out there. Here is where I will get on a soap box. Periodicals like JEMS are good. Scientific medicine periodicals are better. Read Annals of Emergency Medicine or Prehospital and Disaster Medicine. These are studies and are peer reviewed. If you want to attend a conference about the breaking knowledge of medicine, pick something like the "Eagles" Conference (The EMS State of the Sciences Conference) or the annual meeting of the National Association of EMS Physicians. These are where you can learn what is really going on.

6) Look at data. Every last one of us thinks we know the facts in EMS. Data tells us that we are usually wrong. A saying in my Six Sigma training rings like a bell: "What you think you know is wrong." Data helps us discern the truth from myth. Do you have any performance data to look at where you work. This will always be a work in progress, whether you are new at data acquisition or savvy at it. Data tells us that we need to look at an airway tool kit rather than Intubation as the Cadillac of airways.

In all honesty, My personal thinking tells me we need three levels of certification/licensure: Emergency Medical Responder (the First responder), EMT and Paramedic. We simply need to establish a specified standard of care and get everyone there, so that all patients get the most evidence-based care (not always provided by a paramedic. The fact that I think that way does not mean I am acting to try to not have the AEMT. The AEMT is here and will be here to provide care.

The thing we have to be careful about is adapting that certification level because we want to or because we "have that skill now."

We need to make these decisions based on data and proven outcome related facts. We do know one thing. The shorter the training is coupled with infrequency of skill does not deliver good outcomes. If a middle ground certification is to get a more advanced skill then the length and content of training must be equal to that required of the higher level on that subject. Training 90% of ECG rhythms is not safe or fair to the caregiver. Teaching skills without the commensurate A&P educational requirement is not a safe practice. This is why when I hear of "adding" to the middle ground certifications I tend to get vocal.

We need more CPAP, less Lasix. More vascular access, less fluid. More accurate assessment, less immobilization. More reading, less conjecture. If EMS is ever going to be taken seriously, we need to get our behavior under control. We all know of that "one time" when "this" helped "that patient." Is it repeatable? Does it stand up to scientific scrutiny and does it produce an improved outcome?

I heard of a paramedic student recently not wanting to ride with a preceptor because he was being grilled about the services protocols rather than what was taught in class. Get over it. If you are going to ride on any agencies ambulance and deliver care in their name, then you had best have an operational knowledge of their protocol set. Internship is a liability laden privilege. Be glad you get to be there, wherever you may ride. Remember... you are a student. No one has to be a preceptor.

Please think about these things. As I discuss, learn and vote, I am doing so for the patient and to also assure that you have a continuing pathway to success. It is not to harm you in any way.

I was once asked why I did not support a paramedic in a vote regarding their certification. The person asking me thought I should have supported the paramedic because I held the seat representing paramedics. I explained that I could not because of the evidence presented. Sometimes that is just how it is. Without evidence, it is difficult to support. Primum non nocere... First, do no harm. I also support assuring that providers of all types receive appropriate reimbursement. When we make a change that affects reimbursement, we limit what can be provided to patients. That is a simple fact.

Now to change gears... ever notice how many times we are told to be "Strong and Courageous" in the Bible? There are a lot of passages saying just that... look at the book of Joshua alone.

I returned that Friday evening to load five pallets of popcorn into my garage... rather tall pallets at that... my life, each October is popcorn. Our two boys in Scouting sold somewhere in the range of $6,100 worth of the stuff last year. So it begins again.

I learned tonight that a friend of mine's father has Stage 3 cancer in several locations including the lymph nodes. Prayers for my friend, his father and his family would be appreciated.

So, that said, be strong and courageous whatever your vocation of the moment... Faith, Family, Forest or in the Field (of EMS). So this is my idea. A running commentary on these things. It will be my thoughts and I as always take ownership of what I say or write.

Hebrews 4:12
Hebrews 11:1

Next time, I think I am going to tackle a small bit of Scouting stuff and explore why I am a Missouri-Synod Lutheran. Buckle your seat belts and stay tuned.

Spell check does not seem to be working tonight on Blogspot, so I apologize for any errors. Goodnight all...